Major Incident Plan- edited version for publishing on internet. (Includes signposting to other planning arrangements)

Category GPMS Protect (Resilience Planning) Page 1 of 46 Major Incident Plan- edited version for publishing on internet (Includes signposting to other planning arrangements)

Category GPMS Protect (Resilience Planning) Page 2 of 46 IF THIS IS A MAJOR INCIDENT, AND YOU ARE NOT FAMILIAR WITH THIS PLAN, DO NOT READ IT NOW GO STRAIGHT TO THE ACTION CARDS IN Section 5 or contained within your Departmental plan Version 2 Ratified by Amendments issued Author Accountable Officer Responsible Officer Wye Valley NHS Trust Chief Operating Officer Service Unit Manager Urgent Care & Care Closer to the Home Date for Review September 2013 Intended Audience Related Documents Wye Valley NHS Trust Staff and specifically those operating at Strategic and Tactical Levels This Plan contains the generic detail outlining the Wye Valley NHS Trust management, coordination, and activation arrangements which is supported by departmental plans and risk specific plans.

Category GPMS Protect (Resilience Planning) Page 3 of 46 CONTENTS PAGE Section Page (full plan) Document Management and Version Control 6-7 PART 1 GENERAL INFORMATION 1.1 Aim 8 1.2 Objectives 8 1.3 Legal Framework 8 1.4 Defining a Major Incident 9 1.5 1.5.1 1.5.2 Incident levels NHS Commissioning Board Local Area Team Herefordshire Clinical Commissioning Group 1.6 Herefordshire Council Resilience Team 12 1.7 Risk Profile 12 1.8 Roles and Responsibilities of the Wye Valley Trust NHS Trust 13 1.9 Sharing of Information 13 1.10 Planning Arrangements 14 1.11 Summary of Accommodation used in a Major Incident 15 1.12 Testing of Plan 16 1.13 Emergency Planning Group (EPG) 16 PART 2 MANAGEMENT, CONTROL& CO-ORDINATION 2.1 National Command and Control Framework 17 2.1.1 Response guiding principles 18 2.2 Wye Valley Trust Command and Control & incident management process 19 2.2.1. GOLD 20 2.2.2 SILVER 21 2.2.3 BRONZE 21 2.2.4 Department Plans 23 2.2.5 Out of Hospital Response 23 2.2.6 Control of the Hospital Response 23 2.2.7 Preparation of the Hospital 23 2.2.8 Departmental Staff 24 2.2.9 Reporting Areas 24 2.2.10 Identification of Staff 24 2.3 Ambulance (West Midlands Ambulance Service) 24 2.4 Police (West Mercia Police) 24 2.4.1 Casualty Bureau 2.5 Rail Emergencies 25 PART 3 ACTIVATION, INCLUDING ALERT & STAND-BY 3.1 General 27 3.2 Notification Channels 28 3.2.1 Emergency Stand by and Major Incident 28 3.2.2 Internal Major Incident 28 3.2.3 CBRN 28 3.3 Notification Procedures for a Major Incident 29 3.4 Notification to Staff 30 PART 4 ACTION 4.1 Major Incident Stand by 31 4.2 Major Incident Declared 32 4.3 Deceased Persons 33 11

Category GPMS Protect (Resilience Planning) Page 4 of 46 4.4 Hospital Medical Response 34 a. Reception and Immediate Treatment b. Definitive Management 4.5 Relatives 35 4.6 Casualty Documentation 36 4.7 Casualty Property 36 4.8 Remainder of Hospital 36 4.9 4.9.1 4.9.2 Clinical Support Services Radiology Laboratory services a. Blood and Blood products b. Diagnostic Services c. Histopathology Services 4.10 Pharmacy 37 4.11 Non Clinical Support Services a. Portering b. Supplies c. Security d. Catering e. Linen Services 37 f. Domestic Services g. Works 4.12 4.12.1 4.12.2 4.12.3 4.12.4 4.12.5 4.13 4.13.1 4.13.2 4.13.3 4.13.4 4.14 4.14.1 4.14.2 Communications Existing telephones Additional extra lines provided by Service providers Cellular Phones Radios Runners Traffic Overall responsibility Approach Routes Ambulance Circuit Parking Enquiries Enquiries in Person Enquiries by Telephone 4.15 Other Services a. Chaplains b. Volunteers 4.16 Staff Support services 39 4.17 Administrative Services a. Loggist b. Interpreters 39 4.18 Handover 39 4.19 Debrief 40 4.20 Recovery 40 36 38 38 39 39

Category GPMS Protect (Resilience Planning) Page 5 of 46 PART 5 ANNEXES A CONFIDENTIAL: Action Cards 1. Switchboard Operator 2. Site Manager 3. Duty Manager 4. Nurse Coordinator 5. Nurse in Charge A and E Dept 6. Medical Coordinator 7. Chief Triage Officer 8. Major Incident Manager 9. Chief Operating Officer/Deputy 10. Event/Decision Loggist 11. Minute Takers 12. Communications Manager/Officer 43 46 47 48 50 52 54 56 58 60 61 62 B Suggested Template for SITREP 64 C Suggested Agenda for Initial meeting 66 D Drawing suggested lay out of MCI Room 69 E CONFIDENTIAL: MCI Contacts Directory 70 F Glossary of Abbreviations 72 G Publication and distribution list 74 Index of Drawings NHS CB Incident levels 11 NHS, Control and Co-ordination Arrangements 17 Wye Valley NHS Trust Command and Control 19 Incident management process 20 Activation 27 Action Major Incident Standby 31 Action Major Incident Declared 32 Recovery 41 Major Incident Room/MCI Hub 69

Category GPMS Protect (Resilience Planning) Page 6 of 46 Document Management and Version Control a. Prepared by Wye Valley Trust Emergency Planning Officer (EPO) in conjunction with Trust Emergency Planning Group. It is the responsibility of the EPO to ensure that this plan is regularly updated, tested and disseminated on behalf on the Trusts Accountable Officer. b. Version Control This document is version 2 of the Wye Valley NHS Trust Major Incident Plan following a review and rewrite of the previous following substantial change to NHS Emergency Planning Response and Recovery arrangements. It replaces all previous versions of the Major Incident Plan. These should be destroyed securely. These guidelines are under constant review. Any correspondence requesting changes in the plan should be addressed to the Trust Service Unit Manager Care Closer to the Home and Urgent Care, Trust Headquarters, County Hospital, Stonebow Road, Hereford, HR1 2ER. c. Ownership and Authorisation The plan has been authorised by the Wye Valley NHS Trust Quality and Performance Board. To achieve an effective overview and review method the Trust has introduced an Emergency Planning Group (EPG) which consists of representation from across the Trust including its facility partners and the West Midlands Ambulance Service. The Group meets on a regular basis to ensure that emergency planning is a systematic and ongoing process, preparing the organisational response to major incidents/emergencies (the terms have the same meaning and are interchangeable in this document and other similar documents). In developing the plan the Wye Valley NHS Trust has consulted with a wide range of partners. This includes staff, its Emergency Planning Group, Herefordshire Clinical Commissioning Group, NHS England Arden Local Area Team (Emergency Planning Response and Recovery (EPRR)), Local Resilience Forum Partners, Public Health England and Herefordshire Council (Director of Public Health). d. Publication and Distribution All members of the Executive Directory and Management Teams will be issued with a copy of this plan together with key partners, Mercia Healthcare, Sodexo, and Shared Services Partnerships including HOOPLE (Appendix D). The latest version of this Plan is held on the Trust Intranet to enable all staff to have access to it, with hard copies in MCI Room, MCI Coordination Boxes. Additionally, an edited version will be placed on the Trust s website. e. Audience This plan is aimed at Wye Valley NHS Trust staff with a role to play in a major incident, and professional partners.

Category GPMS Protect (Resilience Planning) Page 7 of 46 f. Review As a minimum requirement, this plan will be reviewed annually from the date of publication and following any exercises in which the plan is used, or where legislative or organisational changes occur. Amendments will be issued to the plan periodically and the person incorporating the amendment should sign the amendment record. g. Responsibilities of Plan Holders Plan holders are required to: familiarise themselves with the contents of this Plan; promptly send details of any amendments to this plan to the EPO; receive and promptly insert any amendments issued by the EPO into the plan; and record this action on the Amendment Record on page 7. h. Other Plans and Guidance This plan should not be read in isolation, as there is a significant number of health and multi-agency plans that have been prepared nationally, regionally and locally to complement the response to a major incident. A list of relevant plans is contained in section 1.8 post; however, this list is not exhaustive. i. Testing and Exercises Appropriate training will be carried out to reinforce the plan in a timely manner and testing and exercising will be carried out in order to test and validate this plan. NHS recommendation is that Trust carry out live exercise every three years, table top annually and communication test every 6 months. Internal training is delivered at a number of levels and based on the National Standards for Civil Contingencies. j. Amendment Record Version Issued Change Insert By 1.00 November Re-issued after review of previous plan, John Sharman/Paul 2011 exercise and consultation Dubberley November Reviewed awaiting developments of new 2012 EPRR arrangements 2.00 Re-issued after lessons learnt from Emergo Exercise, implementation of National EPRR arrangements April 2013 and introduction of employing EPO in house replacing previous SLA with Herefordshire Council Paul Dubberley Mel Bolton/Paul Dubberley

Category GPMS Protect (Resilience Planning) Page 8 of 46 PART 1 GENERAL INFORMATION 1. General Information 1.1 Aim The aim of this plan is to set out how Wye Valley NHS Trust (WVT) will manage its response to a major incident, setting out the framework to which WVT departmental plans link. Whilst this plan essentially considers the County Hospital as the site which is central to the WVT response the principles and plan can be applied to other Trust buildings should they become the focus of a major incident. Community Hospitals in particular play an important role in the support of incidents such as mass casualty when the County Hospital would look to accelerate existing patients through the system to enhance existing bed space and additionally redeploy staff to assist in the response effort. 1.2 Objectives The objectives of this plan are to: Set out WVT s role and responsibilities under the Civil Contingencies Act 2004 (CCA 2004), Health and Social Care Act 2013 and supporting guidance and legislation. Define what a major incident is and outline the types of emergency that Wye Valley NHS Trust would be expected to respond to; In the event of a significant incident or emergency the Trust may be required to share their resources as directed by NHS England and specifically it s Arden Local Area Team (LAT) (Arden comprises of Herefordshire, Worcestershire and Warwickshire) Outline the command, control and co-ordination arrangements within the Trust and its links to those maintained by Arden LAT and those maintained and implemented at the multi-agency level by West Mercia Local Resilience Forum (WMLRF) (Forum is aligned to West Mercia Police geographic area i.e. Herefordshire, Worcestershire, Shropshire and Telford and Wrekin). Detail Wye Valley NHS Trust s roles and responsibilities during a major incident and establish a framework within which these can be fulfilled; Provide assurance that Wye Valley NHS Trust meets criteria of NHS Core Standards for EPRR (NHS Commissioning Board Command and Control Framework) during significant incidents and emergencies Identify the arrangements for communicating information to staff, patients and stakeholders both prior to, during and after a major incident; and Set out the process for recovery from a major incident. 1.3 Legal Framework The framework is centred on two central planks the Civil Contingencies Act 2004 and the Health and Social Care Act 2012. The CCA 2004 establishes a statutory framework of roles and responsibilities for local responders. The CCA 2004 is supported by Regulations (The CCA 2004 Contingency Planning Regulations) and statutory guidance (Emergency Preparedness).

Category GPMS Protect (Resilience Planning) Page 9 of 46 It provides the national framework and approach that is utilised by responding organisations across the United Kingdom as it prepares for, responds to and recoveries from emergencies addressing the six principles of Integrated Emergency Management (Anticipation, Assessment, Prevention, Preparation, Response and Recovery) The Wye Valley NHS Trust is a Category 1 Responder as defined by the Act, and therefore has a legal duty to perform an important part of not only managing incidents that occur within the Trust but also to provide a role in the national the emergency response. It is therefore required to: Assess the risk of emergencies occurring and use this to inform contingency planning; Put in place emergency plans; Put in place business contingency arrangements; Put in place arrangements to make information available to the public about civil protection matters and maintain arrangements to warn, inform and advise the public in the event of an emergency; Share information with other local responders to enhance co-ordination; and Co-operate with other local responders to enhance co-ordination and efficiency. April 2013 saw the enactment of the Health and Social Care Act and the establishment of national EPRR Command and Control Framework. The inclusion of, or availability of the Trust Company Secretary maybe crucial to the Trust Control and Coordination teams at both GOLD and SILVER levels since expert knowledge maybe required taking into account factors which may be considered such as the Freedom of Information Act 2000, and the Data Protection Act 1998. 1.4 Defining a Major Incident The CCA 2004 defines an emergency as: An event or a situation which threatens serious damage to human welfare in a place in the UK, the environment of a place in the UK, or war or terrorism which threatens serious damage to the security of the UK. The definition is concerned with consequences rather than the cause or source. For the purposes of this definition, an event or situation threatens damage to human welfare only if it involves causes or may cause: Loss of life; Human illness or injury; Homelessness; Damage to property; Disruption of a supply of money, food, water, energy or fuel; Disruption of a system of communication; Disruption of facilities for transport; or Disruption of services relating to health.

Category GPMS Protect (Resilience Planning) Page 10 of 46 For the NHS, major incident is the term in general use. However, the term emergency may be used instead of incident. Within WVT the term Major Civil Incident (MCI) is commonly used and the terms MCI, Major Incident and Emergency are interchangeable within the context of this document. For the NHS, a major incident is defined by the Department of Health as: Any occurrence that presents serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organisations. On the 1 st April 2013 NHS Commissioning Board (NHS England) became responsible for ensuring and implementing the NHS Emergency Planning Response Recovery (EPRR) effort and will direct and lead the NHS response as necessary. NHS England and locally through its Arden LAT is responsible for leading the mobilisation of the NHS in the event of an emergency or incident and for ensuring it has the capability for NHS control, communication and co-ordination and leadership of all providers of NHS funded care. This plan links to the NHS national Incident Plan maintained by Arden LAT. During an incident the LAT will operate from an Incident Coordination Centre with its primary location at Wildwood (Worcester) or Parkside (Coventry) depending on the location of the incident and the responding staff. The NHS is accustomed to normal fluctuations in daily demand for services and at times this may lead to facilities being fully stretched. Such fluctuations are managed without activation of special measures by means of established management procedures and escalation policies. The Trust has recently introduced an Addendum to this plan which considers those risks and threats that would normally fall short of declaring a major incident and has reviewed its surge planning arrangements There may be other occasions when an incident (internal or external) occurs on a scale that affects our ability to respond within normal resources. If this happens, it may be appropriate to call the Co-ordinating Team together to decide whether the incident requires a special response that may include activating the Major Incident Plan either in full or in part. An Executive Director will make the decision to initiate the call in these circumstances. What is a major incident to the NHS may not be a major incident for other responding agencies. The WVT can therefore declare a major incident when its own facilities and/or resources or those of partner organisations are overwhelmed. A major incident may arise in a variety of ways and the WVT response will be dependent on, and appropriate to, a number of situations including: Big Bang Examples A serious transport accident, explosion, or series of smaller incidents. Rising Tide A developing infections disease epidemic or a

Category GPMS Protect (Resilience Planning) Page 11 of 46 capacity/staffing crisis. Cloud on the Horizon Headline News Internal Incidents Deliberate Release Mass Casualties A serious threat such as a major chemical or nuclear release developing elsewhere and needing preparatory action. Public or media alarm about a personal threat. Fire, breakdown of utilities, major equipment failure, hospital acquired infections, violent crime. Chemical, biological or nuclear materials. Casualty numbers that are beyond the capacity created by the local implementation of major incident plans or other major disruptive challenges to the delivery of health care, regardless of their cause. Pre-planned Events 1.5 Incident levels Major Major events that require planning such as sports fixtures, mass gathering of people, demonstrations etc. NHS CB Incident levels 1 A health related incident that can be responded to and managed by local health provider organisations that requires co-ordination by the local CCG 2 A health related incident that requires the response of a number of health provider organisations across an NHS CB Local Area Team area (Arden) boundary and will require an Arden Team to coordinate the NHS local support 3 A health related, that requires the response of a number of health provider organisations and across a region requiring regional coordination to meet the demands of the incident 4 A health related incident that requires NHSCB National co-ordination to support the NHS and NHS CB response 1.5.1 NHS Commissioning Board Arden Local Area Team (LAT) In the event of a significant health related emergency/incident Arden will direct and control the local NHS response. Details of the arrangements are contained within its Major Incident Plan. Its Incident Management Team (IMT) may be located at its Incident Coordination Centres at Wildwood (Worcester) or Parkside (Coventry) depending on the location of the incident and the responding staff. The strategic aim of all NHS West Midlands staff and organisations operating within this structure with respect to a major incidents and disruptive challenges is to : Save Lives, minimise Ill health and to mitigate the adverse impacts of major incidents that cause (or have the potential to cause) significant disruption to the health of the population and/or normal NHS business.

Category GPMS Protect (Resilience Planning) Page 12 of 46 The above aim will be achieved implementation of the following prime strategic objectives: Provide strong leadership and organisational co-ordination with clear lines of communication during preparedness; response; and recovery phases Coordinate provision of swift and effective health care to those affected escalating as necessary in light of subsidiarity and mutual aid needs Maintain critical business functions and core service delivery through dynamic business continuity management Restore NHS services to normality as soon as possible Contribute appropriately to the overall multi-agency effort Work with partners to mitigate disruption to society Provide appropriate system challenge to NHS organisations, partners and other organisations involved in the response. For example: during the 2009 pandemic repeated assurances processes were undertaken relating to immunisation plans and antiviral collection points (Reproduced from Arden Incident Plan Version 3 10th March 2013) 1.5.2 Herefordshire Clinical Commissioning Group (HCCG) HCCG based at Brockington, 35 Haford Road, Hereford HR1 1SH as a Category two responder under the CCA has a number of duties including the requirement to support Arden LAT should any emergency require wider NHS resources to be moblised effectively mobilizing and coordinating all applicable providers that support primary care services maintain service delivery across their local health economy to prevent business as usual pressures and minor incidents within individual providers from becoming significant or major incidents. This includes the management of commissioned providers to effectively coordinate increases in activity across their health economy which may include support with surge in emergency pressures Site Team has access to Rota for the duty commissioner who is available 24/7. 1.6 Herefordshire Council Resilience Team The Herefordshire Council Resilience Team undertakes the co-ordination of multiagency Silver arrangements (physical meeting or by teleconference), and the activation of the 4 x 4 volunteer drivers. The Resilience Team can be contacted as follows: 1.7 Risk Profile The potential hazards that may affect the communities that form the West Mercia Local Resilience Forum (LRF) geographic area, which includes Herefordshire, have been identified, assessed and then ranked according to severity of potential impact and the likelihood of occurrence, and can be found on the LRF s Risk Register at: http://www.westmerciaprepared.org/index.php?riskcat=-1 The Risk Register takes into account national and regional hazard assessments mirroring the National Capabilities programme. The generic risks categories are Transport Accidents, Industrial Technical Failure, Structural Failure, Severe Weather, Industrial Accidents and Pollution, Public Protest, and Animal Health as well as Human Health for which the NHS generally assumes the role of Lead Responder.

Category GPMS Protect (Resilience Planning) Page 13 of 46 Arden LAT is in the process of developing a Local Health Reduction Partnership (LHRP) risk register which will specifically examine health risk and inform NHS planning arrangements at the local level.. The Wye Valley NHS Trust is represented on the West Mercia Local Resilience Forum (WMLRF) Risk Assessment Sub-Group and at Herefordshire Multi-Agency Tactical Silver Group. Changes to risks and threats are reported to the Trust Risk Manager and captured in the EPG risk register with escalation to the organisational or departmental registers as appropriate. This forms the risk platform to which plans are formulated and exercised. 1.8 Role of WV NHS Trust The generic building blocks to understand roles and responsibilities and statutory responsibilities are contained within in the Civil Contingencies Act, and accompanying Regulations and non statutory Guidance, NHS Emergency Planning Guidance 2005 and LRF Good Practice Guide Joint Emergency Response Arrangements which outlines the key roles and responsibilities placed on the WVT both during the response to, and the recovery from, a major incident. Contextualized but not inclusive the key roles applicable to the NHS are: 1.9 Sharing Information Saving and protecting life - provide a 24 hour emergency management and clinical response; Relieving suffering - provide appropriate clinical settings for the treatment of people with minor injuries and conditions which might include reception centers, minor injury units, Walk in centers, community hospitals and general practice; Containing the emergency limiting the escalation or spread; Providing the public with warning; Protecting the health and safety of personnel; Maintaining normal services at an appropriate level; Facilitating investigations and enquiries (e.g. by preserving the scene and effective records management); Facilitating the physical, social, economic and psychological recovery of the community; and Evaluating the response and recovery effort and identifying lessons to be learnt. Link to the primary care, community and mental health response; Liaise with local authorities; Maintain liaison with and co-ordinate the response with the Strategic Health Authority through the West Midlands Emergency Response Management Arrangements for the NHS West Midlands (ERMA). The key principles are defined within the HM Government Data Protection and Sharing Guidance for Emergency Planners and Responders Non-statutory guidance and are summarised below; Data protection legislation does not prohibit the collection and sharing of personal data it provides a framework where personal data can be used with confidence that individuals privacy rights are respected.

Category GPMS Protect (Resilience Planning) Page 14 of 46 Emergency responders starting point should be to consider the risks and the potential harm that may arise if they do not share information. Emergency responders should balance the potential damage to the individual (and where appropriate the public interest of keeping the information confidential) against the public interest in sharing the information. In emergencies, the public interest consideration will generally be more significant than during day-to-day business. Always check whether the objective can still be achieved by passing less personal data. Category 1 and 2 responders should be robust in asserting their power to share personal data lawfully in emergency planning, response and recovery situations. The consent of the data subject is not always a necessary pre-condition to lawful data sharing. You should seek advice where you are in doubt though prepare on the basis that you will need to make a decision without formal advice during an emergency. A copy of the West Mercia LRF memorandum of understanding is held on intranet emergency planning page. 1.10 Planning Arrangements A myriad of plans and arrangements are maintained at national, regional, LRF, category 1 responders, category 2 responders as well by site specific operators. Importantly Trust plans must be line with published guidance, threat specific plans and the plans of other responding partners. In addition to this Plan, the Wye Valley NHS Trust maintains a number of other specific functional emergency plans. These plans cover a range of activities, which may be needed to support the overall response structure. In addition to electronic copies maintained on the Wye Valley NHS Trust intranet, are hard copies contained within the MCI Control Room (term MCI (Major Civil Incident) is commonly used within Trust but has been replaced by has been replaced by term Incident Coordination Centre(ICC)) and, if the incident determines, its secondary control room. Plans are maintained by departments which link to this plan but other specific plans include: Wye Valley NHS Trust Addendum to Major Incident Plan this plan considers risks that maybe managed without activating Major Incident arrangements including risks presented by severe weather, staff absence (industrial dispute), the working environment, buildings and equipment, fuel shortages, surges in activity, IT and communications and supply chain failure Wye Valley NHS Trust Business Continuity Plan and associated service area plans including recovery Wye Valley NHS Trust County Hospital Lock Down plan Wye Valley NHS Trust Major Outbreak Plan Wye Valley NHS Trust Influenza Flu Plan Wye Valley NHS Trust Health Economy, Ambulance and Social Services Capacity Escalation Plan Wye Valley NHS Trust CBRN Plan (Chemical, Biological, Radiological & Nuclear) Wye Valley NHS Trust maintains an active link to other responding agencies including, NHS England Arden, Herefordshire Clinical Commissioning Group (CCG), Public Health

Category GPMS Protect (Resilience Planning) Page 15 of 46 England (PHE), the Local Health Resilience Partnership (LHRP), the Local Resilience Forum (LRF) and Herefordshire Council. Relevant Plans include; NHS Commissioning Board Arden, Herefordshire and Worcestershire Area Team Incident Response Plan (Version 3 10 th March 2013) Herefordshire LRF Multi-Agency Silver Group Guide Public Health England (PHE) Joint Outbreak Control Plan Herefordshire Council Excess Deaths Plan Herefordshire Council Rest Centre Plan West Mercia LRF Mass Fatalities Plan West Mercia LRF Generic Evacuation Framework West Mercia LRF Humanitarian Assistance Centers Plan West Mercia LRF Fuel Contingency Plan West Mercia LRF Communications Plan West Mercia LRF Resilient Telecommunications Plan West Mercia LRF Joint Emergency Response Arrangement West Midlands Region Scientific Technical Advice Cell (STAC) arrangements West Midlands Region Reception for Military Patients (RAMP). Plan West Midlands Health Region arrangements for dealing with the public health impacts of radiation incidents; West Midlands Ambulance Service (WMAS) Major Incident Plan Copies of Plans are contained on Trust Intranet (Emergency Planning page) 1.11 Summary of Accommodation used in a Major Incident LOCATION

Category GPMS Protect (Resilience Planning) Page 16 of 46 All other wards and departments will be used as normal unless the scale of the emergency requires a review of use. The Co-ordinating Team will make this decision if this becomes necessary. 1.12 Testing of Plan It is the responsibility of all departments and ward managers to ensure their staffs have read the Major Incident Response Plan and understand their role in the Hospital and their departmental response. Testing of staff contact details must be conducted every six months, coordinated by the departmental/ward sister. The Emergency Planning Officer will assist with this if needed. 1.13 Emergency Planning Group (EPG) The EPG provide the focus and internal consultation to achieving the Trusts annual work programme including training and exercises. The work programme is processed in the form of matrix framework centred on the NHS Core Standards for EPRR effective March 2013 and previously used Cabinet Office Expectations and Indicators of Good Practise Framework which continues to be recognised as indicator expected to be met by all Responders.

Category GPMS Protect (Resilience Planning) Page 17 of 46 PART 2 MANAGEMENT, CONTROL AND CO-ORDINATION COBR SAGE Lead Government Department Department of Health NHS England PHE National Office Regioal Government Departments PHE regional NHS England Regional Office West Mercia Strategic Coordinating Group PHE Centres NHS England LAT Arden & Shropshire and Staffordshire (act as Health GOLD at SCG) Herefordshire County Silver Herefordshire CCG (act as initial local Health SILVER) Wye Valley NHS Trust All Cat. 1 & 2 responders have right to attend (cat 1 are expected to attend) CCG will coordinate local Herefordshire County initial health response at Silver level (Glossary of terms is included in appendix I) 2.1 Command, Control and Coordination The above drawing replicates the local control and coordination arrangements aligned to national arrangements that maybe implemented to respond and recovery to a major incident (emergency). Category 1 and 2 responders are legally obliged to share information and cooperate with each other as part of that response. The Trust is a category 1 responder along with emergency service organisations and local authorities.. Gold Strategic decision makers at the local level. They establish the framework within which operational and tactical managers work. Multi-Agency cooperation and coordination at this level is delivered through the Strategic Coordinating Group (SCG) and normally Arden LAT will attend on behalf of the NHS. Silver tactical level of management determining priorities in allocating resources and planning and coordinating tasks. Normally chaired by West Mercia Police and would

Category GPMS Protect (Resilience Planning) Page 18 of 46 meet at Hereford Police Divisional Headquarters in bath Street, Hereford. Bronze reflects the normal day-to-day arrangements for responding to smaller scale incidents. It is the management of the hands on work. 2.1.1 The generic GOLD, SILVER and BRONZE command framework is supported by the use of eight guiding principles anticipation ongoing risk identification and analysis is essential to the anticipation and management of the direct, indirect and interdependent consequences of emergencies; preparedness all organisations and individuals that might have a role to play in emergency response and recovery should be properly prepared and be clear about their roles and responsibilities; subsidiarity decisions should be taken at the lowest appropriate level, with co-ordination at the highest necessary level; local agencies are the building blocks of the response to and recovery from an emergency of any scale; direction clarity of purpose comes from a strategic aim and supporting objectives that are agreed, understood and sustained by all involved. This will enable the prioritisation and focus of the response and recovery effort; information information is critical to emergency response and recovery and the collation, assessment, verification and dissemination of information must be underpinned by appropriate information management systems. These systems need to support single and multi-agency decision making and the external provision of information that will allow members of the public to make informed decisions to ensure their safety; integration effective co-ordination should be exercised between and within organisations and levels (i.e. local, regional and national) in order to produce a coherent, integrated effort; co-operation flexibility and effectiveness depends on positive engagement and information sharing between all agencies and at all levels; and continuity emergency response and recovery should be grounded in the existing functions of organisations and familiar ways of working, albeit on a larger scale, to a faster tempo and in more testing circumstances. http://www.cabinetoffice.gov.uk/content/emergency-response-principles-effective-responseand-recovery

Category GPMS Protect (Resilience Planning) Page 19 of 46 2.2 Wye Valley NHS Trust Command & Control The below diagram demonstrates the generic start towards establishing Wye Valley NHS Trusts Command and Control arrangements and the concept of operations that exist. Information/Intelligence and Communication are the life blood to the response effort - the thinking towards recovery is intrinsically linked to the response. Trust GOLD SILVER Coordination (CO) Team Escalate to NHS England Arden LAT/ Herefordshire CCG CO Triage (A and E Consultant) CO Nursing (Head of Nursing) CO Medical (Obstetrician/ Gynaecologist) Major Incident Manager (service Unit Manager Urgent Care) Warn and Inform (Comms) Intelligence Lock Down Estates Logistics Recovery Integrated Family Health Services Service Unit Director & Service Unit Manager Midwifery Maternity, Gynaecology and Neonatal Childrens and Family Services Care Closer to Home and Urgent Care Service Unit Director & Service Unit Manager Accident and Emergency SPA and Patient Flow Medical Nursing Neighbourhood Teams Therapies Diagnostic and Scientific Services Countywide Specialist Teams Learning Disabilities Day Services Mortuary Emergency Planning Integrated Family Health Services Service Unit Director & Service Unit Manager Surgical Cancer Services Outpatient and Audiology Services##Pharmacy and Medicine Management Dental Patient Access Centre and Business Individual action cards aligned to those who have roles responsibility to the initial response are maintained in the Annex to this plan. Each Department maintains individual Action Cards specific to their role in a major incident including Community hospitals which have a key support role in patient management and their movement.

Category GPMS Protect (Resilience Planning) Page 20 of 46 Incident management process Incident Information (Sitrep) Review and evaluate!!!! Resource Information (Capacity and Capability) CONSIDER Anticipation, Assessment, Prevention Preparation Set Objective(s) and prioritise PLAN (Consider generic plans and build Response and Recovery plan) Control Communicate OUTCOMES Hazards and Safety Information Important to the process is the concept of considering What? So what? and What now? Adopt a risk based decision making process Adapted from model used by Fire Service 2.2.1 GOLD on being informed of an incident it is suggested the initial conference will include all Service Unit Directors, Communications Manager/Officer, and Loggist/Minute Additionally, it may be necessary to obtain legal advice and therefore presence Company Secretary may be needed. Its role is to review and instigate policy, resources and strategy and develop a strategic plan in line with NHS England Arden Local Area Team who has overall responsibility for the NHS response. Suggested actions for development include; Compile/Review Sitrep Agree activation Agree/review objectives set Liaise with Herefordshire CCG and or Arden LAT and agree NHS actions and arrangements Authorise Call in internal support or and request external NHS support Ensure Organisational Log is maintained Review briefing arrangements Develop/review Strategic Plan (includes thinking towards tactics and operational delivery) Risk lead assessment and cataloguing process Task and log Decide Battle Rhythm (linked to Arden, SCG, Herefordshire Silver) Its responsibilities include; To provide leadership for the Trust in dealing with the local implications of a flu pandemic. To ensure effective and on-going communication both internally and externally.

Category GPMS Protect (Resilience Planning) Page 21 of 46 To establish a rota of senior staff in the organization to ensure commitment to Trust, County and NHS England response is achieved. To report to the Trust Quality and Performance Board. To decide decisions on re-deployment of Trust staff deployment including restricting or withdrawing the usual standard of services. To maintain essential services wherever possible. To work collaboratively with Health providers and other organizations. To encourage cohesiveness, resilience and self-help, maintaining trust across organisations and with the public. To ensure full normal services are resumed as soon as possible. To ensure that an audit trail is kept to record key decisions and the reasons for these. Ensure debrief occurs when normality is achieved. A suggested agenda for the initial meeting is contained at Appendix Section 5 of this plan. 2.2.2 SILVER - GOLD will activate/agree SILVER arrangements which are will be drawn from; Major Incident Manager (Service Unit Manager care Closer to the Home and Urgent Care) ; Coordinator Nurse (Head of Nursing or deputy); Coordinator Medical ; Coordinator Triage (A and E Consultant); Consultant Microbiologist; Service Unit manager Women and families; Service Unit Manager Planned(Elective) care; Estates - Sodexo and Mercia. Shared Services including HOOPLE, Human resources IT Occupational Health Quality Safety and Patient Experience Company Secretary Loggist If any of the above is absent, a suitable alternative must be appointed. 2.2.3 BRONZE as the response escalates it may become necessary to create dedicated roles to tasks commonly referred to as BRONZE commanders whose role is to manage and report developments to the task allocated.. It is the norm in response phase to implement functions below which underpin most responses, The listed tasks are by no means conclusive and it maybe that the tasks do not need to be undertaken by person dedicated to do so and can be achieved by person who normally be called to do so as part of their day job. Intelligence - provision of accurate and timely situation reports (Sitreps) is crucial to the decision making process. Communications- both internal and external messages are key. Agreed, timely, and accurate information is imperative to mitigate the effects of an emergency situation.

Category GPMS Protect (Resilience Planning) Page 22 of 46 Internal Regular updates will be necessary and will be as far as possible delivered as part of normal business i.e. daily bed management meetings, staff meetings/briefings,sms text messages and or by e-mail.. Heads of Department will be responsible for developing a system to ensure that staff not on duty or working from home is given updates either through telephone (land line or mobile) or internet contact. External Media will be a major consideration and the Chief Operating Officer and their Trust Communications Team. When appropriate, WVT will collaborate with both County Responders and NHS Responders to deliver a joined up and consistent approach. The West Mercia LRF maintains a Communications Plan a copy of which is held on Trust Intranet Emergency Planning page. The overarching consideration is to identify and target audience for published communications and what particular sections of the public need to know. This includes: survivors those in the immediate vicinity and directly affected, possibly as wounded casualties; those who might be affected by the emergency those nearby who may need to take action to avoid further harm; local people those in the area who may be disrupted by the consequences of the emergency and clean-up process; friends and relatives those who are not directly affected but know or are related to those who might be; the general public those who are not affected but are concerned or alarmed about the wider implications or simply interested; and the media. The Chief Operating Officer will authorise appropriate messages prepared by the Trust Communications Manager/Officer to the media and when requested act as spokesperson or alternatively, nominate suitably trained deputy. The Communications Team will continue to operate from their office in Trust Headquarters throughout duration of incident. The importance of joint media strategy particularly during the golden hour and being proactive are recognised principles for dealing with the media during a crisis. A Media Room will be set up in the Diabetes Centre. The establishment of the briefing centre will be an important consideration which will need careful planning and control. It will be the responsibility of Communications Manager/Officer to implement supported by staff and resources from other areas of the hospital. Visits by VIPs - The Chief Operating Officer, in conjunction with the Medical Co-ordinator, will decide at which stage VIP visitors can be accepted. The MCI Manager, the Medical Co-ordinator, and the Security Officer appointed specifically for this task, will co-ordinate such visits

Category GPMS Protect (Resilience Planning) Page 23 of 46 Logistics capacity and capability of staff, buildings and equipment are what the response is based upon. Non availability of staff and as equipment and medical supplies become scarce are important factors for the decision makers to understand and plan around. MCI Room the Trust maintains the coordination room which will be chiefly used for the implementing Hospital response towards capacity and capability to receive patient A drawing of the set up within the MCI room is attached at appendix D. In the event of a continued escalation the MCI Control Room will continue to control and coordinate patient reception and movement but the need will arise to set up an additional coordination capacity including control room(s) and meeting rooms within the Trust Headquarters to coordinate liaison with other agencies, and link support facilities including that of the hospital estate, security and media handing etc. Set up and coordination of the additional room will be the responsibility of the Nurse in Charge of the A & E Dept. 2.2.4 Departmental Plans Heads of Departments maintain department plans and confidential staff profiles to support the overarching Trust response. Departmental Plans must be reviewed and updated every 12 months. 2.2.5 Out of Hospital Response The out of hospital medical response will be provided by the West Midlands Ambulance Service Medical Incident Manager (MIC) and Medical Emergency Response Incident Team (MERIT). (Copy of WMAS Incident Plan is held on Trust intranet). 2.2.6 Control of the Hospital Response The Co-ordinating Team (SILVER) will control the Major Civil Incident Procedure and will be based in the MCI Room within the A&E Department. The overarching aim linked to the team will be to plan towards, and implement the hospitals capacity and capability to deal with the consequences attached to an emergency situation and in doing so effectively communicate its planned response. Medical Co-ordinator Chief Triage Officer Nurse Co-ordinator MCI Manager Clinical Site Team 2.2.7 Preparation of the Hospital The amount of preparation that is possible depends on the warning given. The priority is for preparation for reception of casualties. This involves preparation of clinical areas as directed by the Nurse Coordinator, assisted by Clinical Site Team who will continue to coordinate Trust capacity and managed by the individual department senior staff. Supporting these efforts and subsequent preparation of non-clinical areas and requirements are the responsibility of the MCI Manager in conjunction with Sodexo and Atkins.

Category GPMS Protect (Resilience Planning) Page 24 of 46 2.2.8 Departmental Staff The Nurse Bank will be established out of hours to call in nursing staff as necessary. Other departments are responsible for keeping an up to date call-in list and for having a departmental plan for staff call-in. Staff with local numbers should be called initially. Calls should not be made via switchboard. The senior staff member on duty/call in each department is responsible for nominating someone to call in additional staff once the Major Civil Incident Plan has been activated. 2.2.9 Reporting Areas Staff and volunteers not tasked individually in the plan should be directed to the Staff Reception Area in Spires Reception where a record will be kept of available staff and volunteers and non-specific tasks will be allocated. 2. 2.10 Identification of Staff It is essential that all staff wear identification badges. Temporary name badges will be issued by staff in the Staff Reception Area or the Voluntary Services Co-ordinator to staff or volunteers respectively who are allocated a specific task. Nobody will be allowed into clinical areas unless they have an identification badge. 2.3 West Midlands Ambulance Service (WMAS) WMAS act as a gateway from the Incident to all other NHS resources and coordinates the NHS/medical resources involved at an incident site, including Voluntary Aid Society assets. They are responsible for the safe decontamination of casualties and their onward treatment until arrival at appropriate destination and recording and collation of casualty information and the appropriate destination to which they have been sent ensuring effective communication with the Trust and to partners who are receiving patients. 2.4 West Mercia Police (WMP) The Police are able to marshal large numbers of resources, e.g. Police Support Units to provide containment, information gathering and a public order capability, as well as specialist resources such as firearms and investigation. Also available are Commanders for Civil Contingencies and critical incident events, Family Liaison Officers(FLO), Senior Investigating Officers(SIO), Counter Terrorist Specialists and a variety of CBRN specialists. 2.4.1 Casualty Bureau Although the Casualty Bureau has a wider remit than just being part of the Police investigation, it does form an integral part of that investigation.

Category GPMS Protect (Resilience Planning) Page 25 of 46 2.5 Rail Emergencies Train Operating Companies have teams of specially selected volunteers who have been trained and equipped to respond to the needs of those affected in the hours and days immediately following a rail emergency. These are referred to as Rail Incident Care Teams.

Category GPMS Protect (Resilience Planning) Page 26 of 46 Part 3 ACTIVATION Sudden Impact Transport Accidents, CBRNe Incident (Chemical, Biological, Radiological, Nuclear or explosion) Mass casualties Internal Incident - Fire Notification Series of small incidents, Infectious disease outbreak including Flu Pandemic Industrial Action Severe Weather Rising Tide 999 call(s) Other calls Liaise with Ambulance to verify Self presenters Surveillance and management of patient flow including potential pressure points monitored as part of core Trust business Major Incident/ Emergency declared by other Agency including Arden LAT, Public Health, Police, Fire, Local Authority etc. Ambulance Accident and Emergency Switchboard First Sitrep METHANE M Major Incident E Exact location T - Type of location H Hazards A Access N Number of casualties E Emergency Services Level 2 Site Manager/Duty Manager Level 3 Duty Manager/Site Manager Level 4 Major Incident Manager/ Duty Executive Officer Addendum to this plan gives guidance as to appropriate C, C & C arrangements for lower level incidents Consider escalation by declaring Standby Major Incident /Major Incident 3.1 General The above drawing demonstrates the lines of communication that exist in response to a sudden impact and rising tide incident.

Category GPMS Protect (Resilience Planning) Page 27 of 46 It is essential that, where possible, that notification channels to the Hospital are clear, and not susceptible to hoaxes. It is also essential that notification to staff is unambiguous. Equally it is important that the Hospital is prepared to meet the consequences attached to an emergency situation whether initiated from an internal or external incident and therefore an early decision to call a major incident allows the development of a proportionate and flexible response. 3.2 Notification Channels 3.2.1 Emergency Standby and Major Incident The usual channel of notification to the Hospital in the event of a Major Incident is through Ambulance Control (normally Hereford & Worcester or Welsh Ambulance Services). The procedures will be implemented from within the hospital if it becomes apparent to Level II Clinical Site Manager (CSM) that a Major Incident has occurred. If notification comes from another source the situation should be discussed with the respective Ambulance Control before the MCI Plan is implemented. 3.2.2 Internal Major Incident The CSM will contact the Head of Nursing (in hours) or Level 3 Manager (out of hours) and the Director on-call, and provide a briefing on the incident. Once all parties have agreed the plan is to be activated, the Level 3 Manager or Head of Nursing will call switchboard and provide notification and place the hospital on standby or declared status. 3.2.3 CBRN Emergency Notification of an emergency requiring decontamination procedure will usually be via Ambulance Control. However, single or multiple contaminated casualties may arrive unannounced in the Accident & Emergency Department (A&E) and the Chemical Decontamination Plan would be activated. Even a single case needing decontamination requires a special response from A&E. The Nurse in Charge or Department lead who consider that a special emergency situation is developing should discuss the matter with the duty Executive Director and consider appropriate escalation response, The response will be proportionate and necessary to the possible consequences and risk that prevails. For example, one of two self-presenters maybe contained and decontaminated without putting the hospital into major incident mode and implementing the management procedures contained within the Major Incident Addendum Plan and supporting CBRN and Lockdown Plans. However, larger numbers of patients being received or areas of hospital becoming contaminated will give rise to major incident being declared.

Category GPMS Protect (Resilience Planning) Page 28 of 46 3.3 NOTIFICATION PROCEDURES FOR A MAJOR INCIDENT

Category Protect Page 29 of 46 Part 4 ACTION 4.1 Standby Major Incident Declared Level 4 Trust GOLD Senior manager/director on call Escalate to Herefordshire CCG / NHS England Arden LAT CO Triage (A and E Consultant) SILVER Coordination (CO) Team CO Nursing (Head of Nursing) CO Medical (Obstetrician/ Gynaecologist) Major Incident Manager (Service Unit Manager Urgent Care) Escalate to Herefordshire CCG Duty Manager Comms (Warn and Inform) Major Incident Stand by Clinic Site Manager Level 3 Cascade on call by relief telephonist Switchboard Nurse in Charge A & E Nurse Coordinator (Head of Nursing HON) Medical Coordinator (Consultant Obstetrician/ Gynaecologist) Service Delivery Managers Senior Duty Porter Consultants Anaesthetics, Orthopaedics, Surgery Medicines Age Care Paediatrics Radiology Biomedical Scientist Haematology Biomedical Scientist Clinical Chemistry The above drawing replicates the standing operating procedure that exists within the hospital during normal activity. Out of hours the Clinical Site Manager who acts as the Single Point of Access, acts as sleeping Silver and in the event of an internal escalation towards or declaration of an Internal Major Incident occurring the Switchboard acts as the conduit to cascade the information to on call staff and level III (Silver), level IV(GOLD) Coordinating Teams and Chief Operating Officer. Initial Actions Duty and or Major Incident and Site Managers supply the initial lead and preparation as Trust makes ready for MCI Incident. Other staff should ensure that the area under their control is ready to manage a large number of casualties in the event of the incident being upgraded to declared.

Category Protect Page 30 of 46 4.2 MAJOR INCIDENT DECLARED In the event of escalation the suggested start point for Trust control and coordination when a major incident is declared. Responsibility for declaring a major incident normally falls to the Trust duty executive (GOLD) Major Incident declared - the hospital sets itself as a receiving hospital to manage the in-hospital response, to collate data concerning casualties, to provide optimum care and assistance to victims and to provide information to the police documentation team as appropriate. Priority will be given to the admission and treatment of cases from the Major Incident and other patients of equal or greater clinical need. Clears lines of communication between units are vital to ensure an efficient and coherent response and recovery are achieved. The following will be Key Administrative Areas Name Location Extension No(s. 4.3 Deceased Persons Deceased patients will not normally be removed from the scene of the incident and will be the responsibility of the Coroner. Patients who die on route to or after they have arrived at the hospital will also be the responsibility of the Coroner.

Category Protect Page 31 of 46 Key considerations for the hospital is to respect the integrity of the bereaved and that attached to the DVI process at the same time ensuring that persons are processed in an expeditious manner to prevent bed blockage. 4.4 Hospital Medical Response The medical response can be broadly divided into 2 phases a. Reception and Immediate Treatment b. Definitive Management 4.20 Recovery The recovery phase is consonant to the response to any major incident and both Control Teams are responsible for ensuring that the Trust returns to normal in a planned way. The Recovery Team membership will be dependent on the impact and consequences to the trust but would normally be chaired by a Service Unit Manager (Silver) reporting to the Chief Operating Officer (GOLD) and will be supported by a operational team. The handover from response team to the recovery is part of a formal process and as a start point the following are considered key objectives Managing the return to normal service delivery; Priority of elective services including the impact on targets;

Category Protect Page 32 of 46 Communication with patients affected by the incident including the rebooking of cancelled appointments; Staffing levels in the immediate future; Identifying patients who require further surgical intervention; Number of beds occupied by major incident casualties including critical care beds and other specialist beds; Support of staff welfare including appropriate counseling; Restocking of supplies and equipment; and Auditing and reporting of the incident The Trust maintains both Corporate and Clinical Business Continuity Management Plans which collate and escalates risks and threats where necessary. The below diagram is adapted from HM Government: Preparing for Emergencies November 2008, a copy of which can be found on the Trust Intranet emergency planning page, and whilst the document seeks to provide guidance and good practice to community events, the principles can be applied to any recovery effort. Humanitarian Assistance Economic Infrastructure Physical impacts (including patients and employees health and finical needs) Psychological impacts Deaths Trust displacement Economic and business recovery Reputational damage widespread concerns Salvage and Insurance Legal Disruption to Trust life (services and business) Disruption to buildings utilities and essential services, catering, portering, transport, etc.) Security of buildings